172.00.08 Ark. Code R. 002
INTRODUCTION
This manual delineates the rules of operation established for the Arkansas Kidney Disease Commission. Changes, additions, and deletions will be made from time to time in order to insure the best possible services for clients with permanent kidney failure who are residents of the State of Arkansas. Rule changes will only be considered during Commission meetings when a quorum is declared. A majority vote is required for any change.
Arkansas Kidney Disease Commission
RULES
AUTHORITY
The Arkansas Kidney Disease Commission (AKDC) was established by the General Assembly of the State of Arkansas through Act 450 of 1971 to establish a program for the care and treatment of persons suffering from chronic renal disease. The legislation charged the AKDC to "provide financial assistance for persons suffering from chronic renal disease who require life-saving care and treatment to the extent as determined by the Commission".
Legislative Findings and Purpose
Legislative findings declared and found that one of the major problems facing medicine and the public health and welfare is the lack of an adequate program to assist in the treatment and cure of persons suffering from chronic kidney disease. It is estimated that a number of citizens of this State annually are confronted with chronic kidney disease, requiring complicated and expensive treatment, which is often beyond the financial resources of such individuals. There is a critical shortage of adequate facilities within the State for the discovery, evaluation, diagnosis, treatment, and cure of individuals suffering from chronic kidney disease. In order to provide for the care and treatment of persons suffering from acute or chronic kidney disease, and in order to encourage and assist in the development of adequate treatment facilities for persons suffering from acute or chronic kidney disease, it is essential that the State develop a program of financial assistance to aid in defraying a portion of the cost for the care and treatment of chronic renal disease to the extent that the individual suffering from such disease is unable to pay for such services on a continuing basis.
COMMISSION
Powers and Duties of the Commission
The Commission shall have the following functions, powers and duties:
* To establish a program to assist suffering from acute or chronic renal failure in obtaining care and treatment requiring dialysis. Such program shall provide financial assistance for persons suffering from chronic renal diseases who require life-saving care and treatment for such renal disease to the extent, as determined by the Commission, that such persons are unable to pay for such services on a continuing basis without causing unjust and unusual hardship to himself and his immediate family, including, but not limited to, a drastic lowering of the standard of living.
* Develop standards for determining eligibility for assistance in defraying the cost of care and treatment of renal disease under this program.
* To cooperate with hospitals, private groups, organizations, and public agencies in the development of positive programs to bring about financial assistance and support of evaluation and treatment of patients suffering from chronic kidney disease.
* To cooperate with the National and State Kidney Foundations, and with medical programs of the State and Federal Government, for the purpose of obtaining the maximum amount of Federal and private assistance possible in support of a kidney disease treatment program.
* Establish criteria and standards for evaluating the financial ability of persons suffering from chronic renal disease to pay for their own care, including third party insurance coverage, for the purpose of establishing standards for eligibility for financial assistance in defraying the cost of such care and treatment from funds approved to the commission for renal disease treatment purposes.
* To accept gifts, grants, and donations from private sources, from municipal and county governments, and from the Federal Government, to be used for the purpose of this Act in defraying costs incurred by persons suffering from acute or chronic renal disease who are unable to meet the total cost of life-saving care and treatment for renal disease.
Commission Committees
Financial Committee
The Financial Committee will be composed of at least two (2) members appointed by the Chairman of the Commission. It will be the responsibility of this Committee to review and make recommendations to the full Commission regarding program rules and practices related to establishing the client financial needs criteria to be utilized by the AKDC.
Medical Committee
The Chairman of the Commission will appoint the Medical Committee. This Committee will be composed of as many as eight (8) members, and will include specialists who treat end stage renal disease (ESRD), and may include others who work in allied medical fields and are knowledgeable about chronic renal conditions. One member shall serve at the discretion of the Chairman of the Commission as chairman of this committee. The Chairman of the Medical Committee must be a physician knowledgeable in ESRD. It will be the responsibility of this committee to review and make recommendations to the full Commission regarding program rules and practices related to the services provided by the AKDC. This committee will also establish the specific medical criteria a client must have in order to receive services provided by the program. The Chairman of the Medical Committee may assist in the application review process to ascertain if the individual applying for services meets the established medical criteria. In certain instances the full Medical Committee may be asked to review an application if such is indicated.
ELIGIBILITY
Persons suffering from chronic renal failure may be referred to the Arkansas Kidney Disease Commission. Referrals will come from physicians, clients themselves, rehabilitation counselors, social workers, hospital personnel, the Association of Kidney Disease Patients, the Arkansas Kidney Foundation, the Social Security Administration, and others including individuals and agencies familiar with the person's kidney disease.
Eligibility Requirements
Eligibility requirements will be applied without regard to sex, race, creed, color, or national origin. With respect to age, no upper or lower limit will be set as a guide to turn away a referral.
No residence requirement, durational or other, will be imposed which would exclude any individual, who lives in Arkansas and makes or intends to make Arkansas home, from receiving services.
Certification by a Nephrologist is required confirming the applicant has a diagnosis of ESRD with an indication that the individual is in need of regular renal dialysis treatments or has been the recipient of a kidney transplant.
Financial need will be considered in determining eligibility.
The AKDC will conform to the policies of the Directive/Protection of Families from Government.
Application for Services
Individuals applying for services available through the program are requested to complete the AKDC Referral Application. Utilization of the AKDC Referral Application (Form KD -1) is preferred as it contains the necessary individual identifying information as well as income, benefit, and asset information to determine financial need. The Referral Application also includes the required Nephrologist certification indicating the applicant has ESRD or been the recipient of a kidney transplant.
Certificate of Eligibility/Ineligibility
A certificate of eligibility-ineligibility (Form KD-10) will be completed prior to the provision of services, or the refusal of services, as the case may be. The AKDC Program Administrator will have the responsibility to review the Referral Application applying the established financial needs criteria. The applicant will be notified if financial need is not met. The signature of the AKDC Program Administrator will only be required on the Certificate of Eligibility/Ineligibility for those applicants not meeting the program's established financial needs criteria. Applications of individuals determined to meet the established financial needs criteria will be referred to the Chairman of the Medical Committee or, if so determined by the Commission Board, a physician employed by Arkansas Rehabilitation Services to ascertain whether the applicant's medical condition is consistent with the established program criteria to be eligible for services. The signature of the AKDC Program Administrator, the reviewing physician, and the Chairman of the Commission is required on the Certificate of Eligibility/Ineligibility for those applicants determined eligible to receive program services. The Vice-Chairman of the Commission will sign in the absence of the Chairman. Applicants and other concerned will be notified of the decision made, whether approved or denied.
FINANCIAL NEED/COMPARABLE BENEFITS
Client's Resources
Every applicant's request for services will be reviewed to determine if other benefits are available. It is the intention of the AKDC to assist all eligible ESRD cases, but only to the extent that such services will supplement other benefits.
Financial need is basic for AKDC services. Many individuals lack adequate financial resources to maintain themselves and/or their dependents and are often unable to meet needs arising from the extraordinary circumstances associated with ESRD. AKDC rules and practices are based on the concept of assisting the client with a limited number of prescriptions as well as some dental and medical services. In determining an individual's financial resources, all resources available to the client and his/her household will be considered. If the applicant is a dependent, the resources of the parent(s) will be determined. The exception is if the applicant is a dependent and is receiving SSI benefits, he/she may be considered a family of one. The Commission members will establish the standards for determining financial need.
When determining financial need, the AKDC will consider the available financial resources of the total household unless an exception exists. Income sources to be considered include wages; business income; social security, SSDI, and SSI benefits; retirement income; veteran's benefits; income from stocks, bonds, or other investments; and other identifiable liquid assets.
Comparable Benefits of the Individual
The comparable benefits provision provides the AKDC with an organized method for assessing an individual's eligibility for benefits under other programs. Any benefits available to individuals under any other program to meet, in whole or in part, the cost of any AKDC service is not a factor in determining eligibility for AKDC services.
Other Resources/ Similar Benefit
Any services that the applicant may receive, or be eligible to receive from other sources will be used first. The AKDC may only supplement these benefits.
Co-Payment
The Commission Board members will establish any co-payment for services that is to be paid by a client of the program. The AKDC has assessed clients a co-payment for prescription drugs to be paid at the point of sale.
EFFECTIVE DATE OF SERVICE
The effective date a client will be eligible to receive paid for services provided by the AKDC will be established by the program. An applicant must be determined eligible prior to program funds being authorized. The AKDC shall not authorize payment for any services prior to the effective date of service.
Financial Cap
The Commission Board members will establish a limit on per client expenditures per state fiscal year. During the course of a fiscal year should expenditures for a client exceed the limit allowed per year the case will be referred to the Commission Board for review to determine a course of action.
Termination of Services
Paid for services provided by the AKDC will be terminated the day a client dies. Eligibility_for paid for services will also be ended the last day of the month a client's course of dialysis is terminated unless the individual has received a kidney transplant. It will be the_practice of the AKDC to mirror Medicare regarding clients receiving kidney transplants.
SERVICES
The availability of funds will influence the services provided by the AKDC. The Commission Board will determine specific services to be funded by the program each fiscal year. Covered services can include: outpatient pharmaceutical drugs, medical services, pre-transplant dental services, transportation, and referral. Specific services to AKDC clients, including those in need of continuing services, will be provided based upon the availability of funds. During the course of a fiscal year should it be determined insufficient monies are available to fund services provided by the program at existing levels for the remaining portion of the fiscal year, the Commission Board will establish the manner in which services will be curtailed, or if required, terminated for the remainder of that fiscal year. Should the curtailing of services result, preference will be given to those in need of continuing services.
Outpatient Pharmaceutical Drugs
The AKDC may pay for a limited number of ESRD related prescription drugs. Medications paid for by the program must be consistent with the approved AKDC drug list. A client co-pay for allowable drugs is required. The AKDC will only participate in the purchase of immuno-suppressant medications as a co-payer. Program co-payment for immuno-suppressant drugs shall not exceed twenty percent of the Medicare allowable rate.
Medical Services
The AKDC may assist in paying for some of the ESRD related medical treatment costs during the Medicare three-month waiting period or when no other coverage exists. Documentation of lack of coverage and prior authorization is required to be eligible for this service. The AKDC shall not provide payment for any durable medical equipment. Payment for any medical service will be consistent with the established fee schedule.
Pre-Transplant Dental Services
The AKDC may assist with dental charges when a dental problem jeopardizes the health and treatment program outlined by the renal specialist and may be covered only for the purpose of kidney transplantation. Payment for services rendered will be prior approved and consistent with the established dental fee schedule.
Transportation
The AKDC may assist in paying for some client transportation costs specifically associated with ESRD treatment. Eligibility to receive this service will be on a prior-approved basis with determination consisting of a review of existing client/household income and expenses, other available resources, and documentation of a lack of other assistance. Reimbursement will be based on a mileage per diem rate with the maximum allowed established by the Commission Board.
Referral Services
The AKDC will assist clients diagnosed with ESRD with referral to other programs including vocational rehabilitation.
Payment for Services to Vendors
The AKDC will process payment for services when in receipt of a signed vendor statement or letter that includes the client's name and other necessary identifiable information, a description of services provided, date(s) of service provision, and cost. Claims for prescription drugs are to be submitted on the AKDC Prescription Drug Claim Form. The AKDC will not pre-pay for a service, only providing payment after the service has been rendered. Requests for payment for services rendered must be received by the program within one calendar year of the date of service. The AKDC will not provide remittance for those requests for payment that exceed the one-year from date of service limit.
Confidentiality, Use, and Release of Client Records and Information
The AKDC will develop and maintain a case record for applicants and individuals determined eligible to receive services available through the program. Client information developed or received by the AKDC will be the property of the program. Information contained in the case record may only be used for determining eligibility/ineligibility for AKDC services, providing payment for services rendered, or other program operations. The AKDC will endeavor to maintain personal information contained in the case record in a secure manner and treat such information with the highest degree of confidentiality.
The AKDC Program Administrator shall be designated as the custodian of applicant and client case records. The Program Administrator will have the responsibility of insuring such information is maintained in a safe and secure manner consistent with State and Federal regulations. The Program Administrator shall provide training to AKDC staff regarding how applicant and client information will be developed, maintained, and shared with affected parties. The Program Administrator will be responsible for the destruction of all closed case files.
When requested in writing, the AKDC will make available to the applicant or client, of if appropriate the individual's representative, information contained in that person's case record. Should the applicant or client or, if appropriate, that individual's representative believes information contained in the case record to be inaccurate or misleading, a written request can be made to the program to amend such information.
In the event another agency or organization requests personal information contained in the case record of an AKDC applicant or client, the program will only release such information with written consent of the applicant or client or, if appropriate, that individual's representative. It will be the responsibility of the AKDC and parties involved to respect the confidential nature of personal information and limit information exchanged to that minimally necessary. The AKDC will release personal information contained in the case record in response to investigations in connection with law enforcement, fraud, and abuse unless expressly prohibited by State and Federal laws and regulations and in response to an order issued by a judge, magistrate, or other authorized judicial official.
172.00.08 Ark. Code R. 002